Confidentiality with children and adolescents — formative SAQs

SAQ 1 — The conditional script and the override (10 marks)

A 15-year-old attends alone for the first time, having previously been brought by a parent. They open with: "If I tell you something, will you tell my parents?" Later in the visit they disclose two weeks of low mood, intermittent self-harm by scratching, and passive thoughts that life is not worth living, but no active plan or intent. [2] [6]

Questions

1. Give the conditional-confidentiality statement you would deliver at the start, and explain why it is preferred to a promise of absolute secrecy. (4 marks) [1] [6]
2. Outline your immediate assessment and management of the low-mood and self-harm disclosure, including the threshold for overriding confidentiality. (4 marks) [6] [8]
3. Explain how you would assess this young person's capacity under the Gillick or Fraser framework, and why capacity is described as decision-specific. (2 marks) [9]

Model answer

Conditional script and why absolute secrecy fails (4). A workable script: "What we talk about is private, between us, unless I'm worried you're at serious risk of being hurt, of hurting yourself, or of hurting someone else, or unless the law requires me to share something. If I ever do need to share, I'll tell you first and we'll plan it together." This is preferred because absolute secrecy cannot be kept — an inevitable override (serious harm, abuse, legal duty) would make the original promise a lie and collapse trust. Conditional framing lets the clinician honour the promise actually made. [2] [1] [6]

Assessment and management of the disclosure (4). Assess suicide risk directly: ideation, plan, intent, means, prior attempts, protective factors and capacity to stay safe. Passive thoughts without active plan or intent, with intermittent superficial self-harm and intact protective factors, may be managed with early close follow-up, a safety plan and connection to psychological support. Active plan or intent triggers the serious-harm override: secure immediate safety, share minimum necessary with crisis team and parent as part of the safety plan, tell the young person what is shared and why. Do not file-and-forget or rely on delayed psychology alone if risk is high. [6] [8]

Capacity assessment (2). Gillick/Fraser asks whether the young person understands the condition, the proposed care, the alternatives and the risks, and can weigh that information rationally and hold it in mind. Capacity is decision-specific because competence for one decision (e.g. engaging with psychological support) does not establish competence for a different or higher-stakes decision (e.g. refusing life-saving treatment), and it can fluctuate with illness and distress. [9]

SAQ 2 — Parental request and the portal breach (10 marks)

A. The parent of a competent 16-year-old phones the clinic demanding the full portal notes from a recent confidential mental-health consultation, which the young person does not want shared. [5]

B. Separately, a 15-year-old is distressed because an insurance explanation-of-benefits statement sent to their parent revealed a contraception consultation. [4]

Questions

1. Outline how you would manage the parental request for the competent young person's information (Part A). (4 marks) [5] [6]
2. Explain the mechanism of the portal/billing breach and the system-level steps to prevent it (Part B). (4 marks) [4]
3. State two documentation requirements that apply to both scenarios. (2 marks) [9] [1]

Model answer

Managing the parental request (4). Acknowledge the parent's concern respectfully, then explain that a competent young person controls their own health information and that parental responsibility does not automatically override that right. Offer to facilitate a shared conversation with the young person's agreement rather than handing over the record against their wishes. Document the request, the response and the young person's stated preference. If a genuine safeguarding concern drives the request, handle that separately through child-protection pathways. [5] [6] [1]

Mechanism and prevention of the portal/billing breach (4). Modern breaches most often arise through infrastructure: billing statements, insurance explanation-of-benefits, patient portals and open-notes regimes surface a sensitive encounter to a parent unless sensitive-note workflows are configured. The 21st Century Cures Act in the United States illustrates how default-open-notes rules threaten adolescent confidentiality. Prevention: apply sensitive-note or confidential-encounter flags, route sensitive results through an alternative channel, confirm local portal and billing configuration, and tell the young person how the system handles their encounter. [4] [1]

Documentation requirements (2). Record the capacity assessment and its reasoning (not just the conclusion), and document the confidentiality discussion, the young person's sharing preference, and the basis for any disclosure or refusal to disclose. [9] [1]